Medicare Prescription
Payment Plan

The Medicare Prescription Payment Plan is a new program for 2025 that will help people with Medicare prescription drug coverage (Part D) who have high out-of-pocket expenses. Individuals can spread out their medication costs in the form of monthly payments over the course of the plan year. 

This program allows you to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy to help you manage your Medicare Part D drug costs. There is no cost to participate in the Medicare Prescription Payment Plan. Participation is voluntary, and you can enroll in this program at any time.

If you select this payment option, each month you’ll continue to pay your plan premium (if you have one), and you’ll get a bill from Gold Kidney Health Plan to pay for your prescription drugs, instead of paying the pharmacy.  

You may request retroactive election into the Medicare Prescription Payment Program. In order to request a retroactive election, for covered prescription(s) you paid your cost share for, you must meet the following: 

You reasonably believe any delay in filling the prescription(s) due to the 24-hour timeframe requirement to process your program election may seriously jeopardize your life, health, or ability to function, and you request retroactive election within 72 hours of the date and time the urgent prescriptions(s) were billed to us at the pharmacy.

To find out more about the program and for examples on how monthly billing is calculated, please visit this website.

 

Fact Sheets

English
Spanish

To register for the Medicare Prescription Payment Plan, please complete the form below.

M3P

Personal information

xxxx-xxx-xxxx
MM/DD/YYYY
xxx-xxx-xxxx
Permanent residence street address
Permanent residence street address
Street Address
Address Line 2
City
State/Province
Zip/Postal
Mailing address (if different from permanent residence street address)
Mailing address (if different from permanent residence street address)
Street Address
Address Line 2
City
State/Province
Zip/Postal
Who is completing this form?

Signature and Agreement

Entering your name below acts as a legally binding signature, confirming you
would like to opt in to the Medicare Prescription Payment Plan.
  • I understand this form is a request to participate in the Medicare Prescription Payment Plan. My insurance plan will contact me if they need more information.
  • I understand that signing this form means that I've read and understand the form and the terms and conditions below.
  • My insurance plan will send me a notice to let me know when my participation in the Medicare Prescription Payment Plan is active. Until then, I understand that I'm not a participant in the Medicare Prescription Payment Plan.
 

Terms and conditions

The Medicare Prescription Payment Plan is a new payment option in the Inflation Reduction Act that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January – December). Your drug coverage offers this payment option and participation is voluntary. There’s no additional cost to participate in the Medicare Prescription Payment Plan. By opting-in to the Medicare Prescription Payment Plan, you agree to the following terms and conditions:

  • You must have active Part D coverage.
  • You understand that you have the option to leave the plan at any time but will still be responsible for any drug costs already incurred.
  • You will be billed monthly. This payment is separate from any plan premiums (if applicable).
  • Your payments may change each month if your prescriptions change month over month.
  • You are responsible for paying your bill each month, on or before the due date.
  • If you miss a payment, you will be sent a reminder to make payment. If you do not pay your bill by the due date listed in that reminder, you will be subject to removal from the Medicare Prescription Payment Plan.
  • Removal from the Medicare Prescription Payment Plan does not impact your payment requirements. If terminated from the program, you remain obligated to pay past due amounts and may continue to receive bills for outstanding payments.
  • Late payments made pursuant to the Medicare Prescription Payment Plan are not subject to interest or additional fees.
  • If you are removed from the Medicare Prescription Payment Plan, this will not impact your current drug coverage.
  • Removal from the Medicare Prescription Payment Plan may impact your eligibility to opt-in in the program in the future.

Representative Signature and Agreement

Please enter your own information, not the member's. Your signature certifies that you're authorized under state law to fill out this participation form and have documentation of this authority available if Medicare asks for it.

Personal representative or caregiver address
Personal representative or caregiver address
Street Address
Address Line 2
City
State/Province
Zip/Postal
xxx-xxx-xxxx

Entering your name below acts as a legally binding signature, confirming you would like the member to opt in to the Medicare Prescription Payment Plan.

  • I understand this form is a request for the member to participate in the Medicare Prescription Payment Plan. Their insurance plan will contact them if they need more information.
  • I understand that signing this form means that I've read and understand the form and the terms and conditions below.
  • The insurance plan will send the member a notice to let them know when their participation in the Medicare Prescription Payment Plan is active. Until then, I understand that the member is not a participant in the Medicare Prescription Payment Plan.

 

Terms and conditions

The Medicare Prescription Payment Plan is a new payment option in the Inflation Reduction Act that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January – December). Your drug coverage offers this payment option and participation is voluntary. There’s no additional cost to participate in the Medicare Prescription Payment Plan. By opting-in to the Medicare Prescription Payment Plan, you agree to the following terms and conditions:

  • You must have active Part D coverage.
  • You understand that you have the option to leave the plan at any time but will still be responsible for any drug costs already incurred.
  • You will be billed monthly. This payment is separate from any plan premiums (if applicable).
  • Your payments may change each month if your prescriptions change month over month.
  • You are responsible for paying your bill each month, on or before the due date.
  • If you miss a payment, you will be sent a reminder to make payment. If you do not pay your bill by the due date listed in that reminder, you will be subject to removal from the Medicare Prescription Payment Plan.
  • Removal from the Medicare Prescription Payment Plan does not impact your payment requirements. If terminated from the program, you remain obligated to pay past due amounts and may continue to receive bills for outstanding payments.
  • Late payments made pursuant to the Medicare Prescription Payment Plan are not subject to interest or additional fees.
  • If you are removed from the Medicare Prescription Payment Plan, this will not impact your current drug coverage.
  • Removal from the Medicare Prescription Payment Plan may impact your eligibility to opt-in in the program in the future.
I confirm that I am the personal representative or caregiver for this individual
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For all inquiries, please call Member Services at (844) 294-6535

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